Hepatitis C Presentation

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Hepatitis C Presentation Resource Manual
To provide basic hepatitis C education and
support materials to methadone clinical staff
enabling them to better serve their hepatitis C
patients.
Goal

• Upon completion of the presentation the audience
  should have a basic understanding of
• Hepatitis C virus and how it effects the liver
• Transmission and risk factors
• Diagnostic tests
• Natural history and progression of hepatitis C
  and HIV/HCV Co-infection
• Treatment options western and alternative
  medicine, including nutritional requirements

Objectives

• Speakers notes
• Handouts
• Pre/post tests
• Presentation documentation
• Patient support resources

Resource Manual Contents
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HEPATITIS Focus on Hepatitis C

• Hepatitis Education for Opioid Treatment Providers

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Hepatitis A, B and C
Hepatitis means liver inflammation. The three
most common are hepatitis A, B C.  

• Hepatitis A
• Self-limiting, never becomes chronic.
• Hepatitis B
• Often asymptomatic in the early stages.
• Becomes chronic in only 10 of the cases.
• Hepatitis C
• Often asymptomatic in the early stages.
• Becomes chronic in 85 of people exposed to it.

Your handout will explain these differences,
similarities and transmission modes.
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The Livers Functions

• Acts as a chemical powerplant
• Produces clotting factors
• Produces proteins
• Filters toxins
• Stores vitamins nutrients
• Regulates hormones

Art work courtesy of Dr. Brad Selby
Administrative Director USC Multi-Organ
Transplant Program
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The Hepatitis C Virus

• Genus Flavivirus
• Single stranded RNA molecule
• Blood borne
• Infects the liver
• Mutates rapidly

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Risk Factors( High Risk )

• Injection intranasal drug use
• Blood transfusion prior to 1992
• Clotting factors prior to 1987
• Hemodialysis
• 5 needle stick exposure
• 3-5 babies born to infected mothers

Source NIH Consensus Statement 2002
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Risk Factors( Lower Risk )

• Sharing personal hygiene items with an infected
  person. (toothbrushes, razors, scissors and nail
  clippers)
• Contaminated tattoo needles and ink
• Contaminated body piercing implements
• Unprotected sexual behavior with multiple
  partners
• People with STD history
• Viet Nam era military service

• Source NIH Consensus Statement 2002
• Source CDC Presentation by M.J. Alter
• Source Testimony of Gary A. Roselle, M. D.
  Program Director for Infectious Diseases Veterans
  Health Administration Department of Veterans
  Affairs.  Before the Subcommittee on Benefits
  Committee on Veterans Affairs U.S. House of
  Representatives April 13, 2000

HCV transmission is blood to blood.
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Testing and Tests
Antibody Response Tests

• Elisa III (used since 1996)
• RIBA (supplemental test)
• HCV/RNA by PCR (confirmatory test )

Viral Particle Test
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Symptoms
Many HCV positive patients are asymptomatic. Some
of the most commonly reported symptoms are

• Fatigue
• Muscle / joint pain
• Headache
• Anorexia
• Right Upper Quadrant Pain

These symptoms are not exclusive to HCV infection
alone.
Art work courtesy of Dr. Brad Selby
Administrative Director USC Multi-Organ
Transplant Program
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Natural History of HCV
Initial HCV Infection Acute Phase Elevated
Enzyme Levels
Six Months Post Infection Naturally Clear
Virus Normal Enzyme Levels 15
Six Months Post Infection Chronic Hepatitis
C Inflammation 85
Slow or No Progression To Fibrosis 80
Liver Failure
Cirrhosis Death of Liver Cells Compensated Decompe
nsated 20
Possible Liver Transplant and/or Death
Liver Cancer 4 per year
The CDC estimates that hepatitis C is
responsible for 8,000 to 10,000 deaths per year
and could increase to 38,000 by the year 2010,
surpassing annual HIV/AIDS deaths.
No Adverse Effect
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Cirrhosis
Several co-factors play an important role in the
development of cirrhosis 20 of people infected
with hepatitis c virus develop cirrhosis.

• Age at the time of infection
• Alcoholism (studies show that alcohol is a very
  important co-factor in the progression of chronic
  hepatitis to cirrhosis)
• Co-infection with HIV
• Co-infection with active hepatitis B virus.

The incidence of hepatocellular carcinoma (liver
cancer) is 4 per year in patients with
cirrhosis. Development of hepatocellular
carcinoma is rare in patients with chronic
hepatitis C who do not have cirrhosis. Source
EASL International Consensus Conference on
Hepatitis C (April 15 21, 2002, Madrid, Spain)
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End-Stage Liver Disease

• Ascites
• Jaundice
• Bleeding - varices
• Mental confusion
• Weight loss
• Severe itching
• Edema

Photo courtesy of Jules Levin NATAP
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Ways to Slow Progression

• NO ALCOHOL
• Heart healthy diet
• Moderate exercise
• Vaccinate for HAV HBV
• Prudent use of all medications (prescription and
  over the counter)

In the absence of conclusive data, a conservative
approach is taken and alcohol abstinence is
usually recommended. Source NIH Consensus
Conference
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Possible Related Problems
These conditions do not indicate HCV infection
but testing should be considered if no other
cause can be identified.

• Kidney Damage
• Cryoglobulinemia
• Autoimmune Disorders
• Skin Conditions
• Thyroid Disease
• Type II Diabetes
• Liver Cancer

Source NIH Consensus Development Conference
Statement. Management of Hepatitis C 2002
Art work courtesy of Dr. Brad Selby
Administrative Director USC Multi-Organ
Transplant Program
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HCV/HIV Co-Infection
When a person has HIV and hepatitis C, it's
referred to as co-infection. The precise number
of co-infected people in the United States has
yet to be determined. However, various studies
estimate that approximately 300,000 people with
HIV are co-infected with hepatitis C (30).

• If a person has HIV, they should
• Be tested for hepatitis A, B and C
• If negative for A and B, they should talk to
  their doctor about getting vaccines for A and B.
• Find a doctor(s) knowledgeable about both HIV
  and HCV, and start discussing treatment
• Strategies for HIV and HCV.
• Discussions about treatment strategies should
  include consideration of the benefits and risks
  of immediate or deferred HCV treatment. Decisions
  to treat should be made on an individual basis.

Source HCV/HIV Co-infection Handbook National
AIDS Treatment Advocacy Project (NATAP)
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Treatment
The decision to treat is a complex issue which
must be made in consultation with a qualified
physician, taking into consideration the
following variables

• Age of the patient
• General state of health
• Risk of cirrhosis
• Likelihood of response
• Other medical conditions that may decrease life
  expectancy or contraindicate the use of
  interferon or ribavirin.
• Patients with moderate/severe necro-inflammation
  and/or fibrosis should be treated

Source EASL International Consensus Conference
on Hepatitis C (February 26-28, 1999, Paris,
France)
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Treatment Options
Currently there are only two FDA approved options
for treatment of HCV infection. All treatment
decisions should be made by the patient and their
treating physician.

• Interferon / Ribavirin (combination)
• Pegylated Interferon / Ribavirin (combination)

Other therapies are in various stages of clinical
trials
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Alternative Treatment
Some alternative treatments may be useful for
easing side effects. No herb or known herbal
treatment will cure the virus.
Possible helpful alternative treatments
These herbs may be harmful to the liver

• Massage therapy
• Aroma therapy
• Milk thistle ( data anecdotal )

• Senna
• Heliotropium
• Jin Bu Huan
• Sassafras
• Skullcap
• Germander
• Comfrey
• Valerian
• Pennyroyal

Extreme caution should be taken in the use of
herbals.
Source NIH, NCCAM, May 2000
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Dietary Guidelines
There are no dietary guidelines for people with
HCV without advanced cirrhosis.
A diet which would be considered appropriate for
any healthy person is recommended. If
supplementary vitamins are required a daily multi
vitamin without additional iron is suggested.
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Counseling Guidelines

• Encourage at risk patients to get tested
• Encourage changes in life style
• Encourage the sharing of HCV status with clinical
  staff
• Have current and accurate information available
  to the patients
• Have support resources available to the patients
• Provide referral services
• Make patients aware of high risk behavior
• Encourage follow-up lab testing
• Encourage patients to take advantage of support
  programs

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Most importantly Listen to your patients Dr.
Vincent Dole